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Dictation vs. Templates

November 18, 2010

Medicine is moving into the electronic information age.  Slowly, perhaps glacial, but moving there nonetheless.  Unfortunately, there needs to be a major paradigm shift in medicine for this move to be truly effective, but we do not appear to be getting there in the near future.  Instead, we are using electronic medical records to mimic what we have been doing for decades on paper.  Toward that end, however, there are some methods that are better than others.

Clinical notes are a key part of medical records.  Physician notes serve to assess the patient’s condition and progress, summarize the pertinent findings of various examinations, and outline the treatments planned for the patient’s condition(s).  Nursing notes document the patient’s subjective and objective findings, verify treatments provided, and note the time at which medications were administered. 

Several tools have been developed to facilitate the documentation process.  Dictation and transcription have been present for decades, and have been used primarily by physicians for their notation of history and physical examinations, operations, consultations, discharge summaries, and even progress notes.  There tends to be some standard formatting in these notes, primarily following the “S-O-A-P” (for Subjective – Objective – Assessment – Plan)  However, beyond that, there is little consistency in the notes.  More importantly, the dictated notes often leave out information because it may slip the dictating physician’s mind.

Electronic medical records often have tools to provide a significant improvement over dictated records.  Theses include the use of templates for the various types of notes that must be generated.  Among the improvements templates provide are :

  • standardized formatting of notes, making it easier (and quicker) for users to find specific pieces of information,
  • prompts for data entry, improving the likelihood that required elements are entered in the not for billing, medicolegal, or regulatory purposes,
  • the opportunity to carry unchanged information forward from previous notes, charting by exception those items that have changed,
  • an improved ability to extract and compile information through electronic parsing from many notes and many patients, enabling improved capabilities for research and performance improvement purposes.

Templates also provide a distinct advantage to the physician over dictations: speed.   A well-constructed template can be completed within minutes or even seconds, depending on its complexity and the physician’s familiarity.  Dictation can also be performed quickly by speed-talkers.  However, it then must go to transcription and then be returned to the physician for review.  To save time, many physicians practice the unsafe act of signing without reading.  Those who play it safe do read and edit their transcriptions, but must then wait again for the corrections to be made for the final saved version to be available.

On the other hand, once the template is completed in a few key strokes, it’s done.  While there is often a significant investment of time in developing the template, the overall time savings for the remainder of a career is substantial.

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